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Undergraduate Withdrawal Application


Mail to: UNC at Pembroke

               Office of the Registrar

               P.O. Box 1510

              Pembroke, NC 28372


Fax:        910.521.6328


Phone:  910.521.6298

Your application to The University of North Carolina at Pembroke has been submitted, however, your application will NOT be considered complete until you have finished the last two steps. To ensure your application for withdrawal is processed as soon as possible:

  1. Print this page, sign it, and submit it to the Office of the Registrar
  2. Please print two copies of this page and keep one for your records
  3. Return the other one signed and dated to the Office of the Registrar

I understand that by signing this application

  • Grades of W count in attempted hours for the purpose of calculation for Tuition Surcharge. (*Exception: WX grades)
  • Grades of W do not count toward full-time (12 hours undergraduate) (9 hours graduate) enrollment or insurance certification.
  • Financial Aid, scholarships, athletic eligibility and visa status may be affected for students who fall below full-time status.
  • Financial Aid violation of the 67% rule will have an impact on future aid.
  • Students receiving VA benefits must inform the VA certifying official in Financial Aid.

Is this a withdrawal for extenuating (WX) circumstances?   YES______      NO_______

*The Associate Vice Chancellor for Enrollment may approve withdrawal from a course or courses for extenuating circumstances (WX). Unsatisfactory academic performance does not constitute an extenuating circumstance. Legal or medical documentation MUST be attached for consideration. (see p.66 of the 2014-15 Academic Catalog) ***

State extenuating withdrawal reason here:________________________________________________________________________________________ .

(Attach letter and medical/legal documentation to this form.  Take this form and other documents to the Assistant Vice Chancellor for Enrollment, Second Floor, Lumbee Hall, Room 210).

Approval as Required:____________________________________________________________________ Date: _______________________________ .

                                            Assistant Vice Chancellor for Enrollment

  • I understand that the last date of attendance is the date the form is electronically submitted to the Registrar’s Office.
  • I certify that the information I have given on this application is complete and correct.  Any willful misrepresentation of fact may be cause for withdrawal of my application from consideration, cancellation of admissions or registration, or suspension from the university.
    • I hereby acknowledge that providing my Social Security number is voluntary, is requested by the institution solely for administrative convenience and record-keeping accuracy, and is required only to provide a personal identifier for the internal records of the institution.
    • I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution but that the institution may divulge the content of the application only as permitted under the Family Educational Rights and Privacy Act of 1974 if I am, or have been, in attendance at this institution. 
    • Adjustments to my semester charges will be calculated based upon the university refund policy ( ).
    • If financial aid or other outside payment sources have been utilized, then adjustments to those payments may need to be recalculated to comply with required funding guidelines, which may result in a debt owed to the university.

Please print name: __________________________________________________




Signature of applicant :_________________________________________________________________________


Signature of parent or Guardian (if under 18): _______________________________________________________

The University of North Carolina at Pembroke and all of its constituent institutions are committed to equality of opportunity. There shall be no discrimination within the university against applicants, students, or employees on the basis of race, color, religion, gender, age, disability, or national origin, consistent with the provisions of applicable state and federal law.

*This publication is available in alternative formats upon request.  Please contact Disability Support Services, DF Lowry Building, 910-521-6695.